Doctors are missing subtle warning signs of heart attack

Patients whose heart attacks were labelled as secondary diagnosis were more likely to die than those whose primary cause of admission was a heart attack.

A new study found that around 16% of patients who died of a heart attack were admitted for secondary conditions, but subsequently died of heart attack.

They believed that the patients would have presented with symptoms of fainting, shortness of breath and chest pain within 28 days before death, yet doctors had missed the primary diagnosis.

“Doctors are very good at treating heart attacks when they are the main cause of admission,” said lead author Dr Perviz Asaria from Imperial College in London.

“But we don’t do very well treating secondary heart attacks or at picking up subtle signs which might point to a heart attack death in the near future.”

Heart attack recorded as a co-morbidity

The authors of the study, which recorded heart attacks between 2009 and 2010, explained that doctors might not have been alert to the signals of an approaching fatal heart attack because there was no obvious damage to the heart at the time.

Patients can have two or more chronic diseases which can trigger interrelated complications. This throws light on the “under-investigated role” of fatal heart attacks, as records of admitted patients showed heart attack as a co-morbidity, primary diagnosis of a heart attack was missed.

“Unfortunately, in the four weeks following a hospital stay, nearly as many heart attack deaths occur in people for whom heart attack is not recorded as a primary cause, as occurring after an admission for heart attack,” said Asaria.

The researchers have urged further research to establish whether these admissions could represent opportunities to reduce the mortality burden.

Professor Majid Ezzati, the co-author, suggested having updated guidance for healthcare professionals, changes in clinical culture, or allowing doctors more time to examine patients and look at their previous records.

“What we are now asking is, if symptoms are being missed where they could have been discovered using the available information, how should care now be organised and what changes need to be made to prevent unnecessary deaths,” said Ezzati.

Nurse’s heart attack symptoms diagnosed as panic attack

Alison Fillingham, 49, a homecare nurse, had a persistent pain in her neck and collar bone, but was initially diagnosed with a panic attack by the paramedics. Subsequent blood tests in hospital revealed that she had a heart attack.

"I've been a nurse for 24 years but I didn't think it was anything to do with my heart. My symptoms were not typical. You expect central chest pain. You think of people clutching their chest but it wasn't like that at all."

She added, "If my heart attack hadn't been picked up in hospital, the artery would have blocked completely and I wouldn't be here now."

"While many heart attacks present with classical pain in the chest in people who smoke and have other risk factors for heart disease, many heart attacks don't present this way and in people not obviously at high risk,” said a spokesman from the Royal College of Physicians (RCP).

The challenge now is to “accurately and speedily diagnose” the patients to offer the best care, according to the RCP spokesman, by educating the public, GPs, paramedics and Emergency Department doctors.

Asians having heart attacks at a younger age

The World Health Organization has projected Asia as having the largest increase in heart failure. Every day, 16 people die from cardiovascular disease in Singapore, and accounted for 29.6% of all deaths in 2015. In Malaysia, it is the principal cause of death over the past 10 years - from 2005 to 2014 - at 13.5% in 2014.

A study by the National University of Singapore (NUS) showed that Asians get heart attacks at least 10 years earlier than their Western counterparts, the average age being 60 in Asia compared to 72 in the United States and 70 in Europe.

Assoc Prof Carolyn Lam, the principal investigator NUS, said, “The frightening finding is that heart failure affects Asian patients at a much younger age than in Western countries, and within Asia itself there is tremendous diversity in disease characteristics.”

Hence, with the increasing risk of cardiovascular diseases for the Asian population, it serves as a reminder that there is a need to recognise the consequences of missing the subtle warning signs of heart attack.

The British Heart Foundation associate medical director, Professor Jeremy Pearson described the failure to detect warning signs as concerning and “these results should prompt doctors to be more vigilant, reducing the chance that symptoms are missed, ultimately saving more lives.” MIMS

At the recent Malaysian Community Pharmacy Business Forum (MyCPBF), a discussion forum was held on the subject of “Transcending Primary Healthcare Services: The Future of Specialized Pharmacy Services and Pharmacy Specialization”.